Healthcare Provider Details

I. General information

NPI: 1538400585
Provider Name (Legal Business Name): SONIA VENEGAS MEZQUITA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 LA TIJERA BLVD STE 408
LOS ANGELES CA
90045-3950
US

IV. Provider business mailing address

8616 LA TIJERA BLVD STE 408
LOS ANGELES CA
90045-3950
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7827
  • Fax:
Mailing address:
  • Phone: 310-337-7827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-12538
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number33341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: